1 2017 Medicare Advantage Plans in Maricopa County There are a variety of different types of Medicare Health Plans to choose from. The attached comparison sheets should be used as a guideline in selecting the type of health plan that meets your individual needs. Things to consider in choosing a plan include cost, choice of doctor, benefits, prescription coverage, flexibility and convenience. The following types of health plans are available to most individuals enrolled in Medicare living in Maricopa County: 1. Health Maintenance Organizations (HMO) Pg. 3 2. Preferred Provider Organizations (PPO) Pg. 25 And Private Fee for Service Plans Most current revision: 6/20/2017 BENEFITS ASSISTANCE PROGRAM A State Health Insurance Assistance Program (SHIP) A program of the Area Agency on Aging, Region One 1366 East Thomas, Suite 108, Phoenix, AZ 85014 602-264-2255 This project was supported in part by grant number 15AAAZMSHI, from the U.S. Administration for Community Living, Department of Health and Human Services, Washington, D.C. 20201. Grantees undertaking projects under government sponsorship are encouraged to express freely their findings and conclusions. Points of view or opinions do not, therefore, necessarily represent official Administration for Community Living policy.
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2017 Medicare Advantage Plans
in Maricopa County
There are a variety of different types of Medicare Health Plans to choose from. The attached comparison sheets should be used as a guideline in selecting the type of health plan that meets your individual needs. Things to consider in choosing a plan include cost, choice of doctor, benefits, prescription coverage, flexibility and convenience. The following types of health plans are available to most individuals enrolled in Medicare living in Maricopa County: 1. Health Maintenance Organizations (HMO) Pg. 3 2. Preferred Provider Organizations (PPO) Pg. 25 And Private Fee for Service Plans
Most current revision: 6/20/2017
BENEFITS ASSISTANCE PROGRAM A State Health Insurance Assistance Program (SHIP) A program of the Area Agency on Aging, Region One 1366 East Thomas, Suite 108, Phoenix, AZ 85014 602-264-2255
This project was supported in part by grant number 15AAAZMSHI, from the U.S. Administration for Community Living, Department of Health and Human Services, Washington, D.C. 20201. Grantees undertaking projects under government sponsorship are encouraged to express freely their findings and conclusions. Points of view or opinions do not, therefore, necessarily represent official Administration for Community Living policy.
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Health Maintenance Organizations (HMO) A group of doctors, hospitals, and other health care providers who agree to give health care to Medicare beneficiaries for a set amount of money from Medicare each month. In an HMO, you generally must get all your care and services from doctors or hospitals in the plan’s network (except emergency or urgent care). You generally must see a primary care doctor to get a referral before you see any other health care provider. If you get health care outside the plan’s network, you may have to pay the full cost. Plans with Prescription Drug Coverage: Page 1. AARP Medicare Complete Plan 1 3 2. AARP Medicare Complete Plan 2 5 3. Aetna Medicare Prime Plan 7 4. Blue Medicare Advantage Classic 9 5. Blue Medicare Advantage Plus 11 6. CIGNA HealthSpring Preferred 13 7. Health Net Ruby 1 15 8. Health Net Ruby Select 17 9. Humana Gold Plus 19 10. Humana Gold Plus 21 Plans WITHOUT Prescription Drug Coverage: 1. Health Net Green 23
Preferred Provider Organizations (PPOs) begin on page 25
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AARP MedicareComplete Plan 1 (HMO) Plan Number H0609-026 STAR RATING = 4.5 STARS
United Healthcare 1-800-555-5757
aarpmedicareplans.com Out-of-Network Services No coverage Additional Monthly Premium for this plan $0.00 Maximum out-of-pocket limit $5,500.00 Inpatient Hospital Optum Medical, Banner Health, Phoenix Direct Networks Only Co-pay per day for days 1 –4 $395.00 Co-pay per day for days 5 – beyond $0.00 Skilled Nursing Facility Co-pay per day for days 1 – 20 $0.00 Co-pay per day for days 21 – 55 $160.00 Co-pay per day for days 56 – 100 $0.00 Outpatient Mental Health Co-pay per visit $30.00 to $40.00 Emergency/Urgent Care Co-pay per hospital emergency room visit $75.00 Co-pay per visit for urgent care $30.00 to $40.00 Foreign Travel Emergency Coverage Check with plan Ambulance Services Co-pay per trip $250.00 Physician Services Co-pay for Primary Care Physician $10.00 Co-pay for Specialist $45.00 Physical, Occupational, Speech Therapy Co-pay per visit $40.00 Routine Podiatry Service Co-pay per visit (Medicare covered and up to 6 supplemental visits) $45.00 Chiropractic Care Co-pay per visit $20 Diagnostic Tests, X-Rays, and Lab Services Clinical/diagnostic lab service $9 to 20% Outpatient Services Facility co-pay at ambulatory surgical center 20% Facility co-pay per outpatient hospital facility visit 20% Prescription Drugs See Your Plan Comparison
or Contact plan Home Health Care Co-pay per visit $0.00 Durable Medical Equipment (DME) Co-pay per item for Diabetic supplies $0.00 Co-pay per piece of equipment 20% Co-pay per prosthetic device 20% Vision Services Co-pay per Medicare covered eye exam & eyewear post-cataract surgery $0.00 to $20.00 Co-pay per annual vision exam $20.00 Frames/lenses/contacts benefit (every 2 years) $70.00/NO COST/$105.00 Hearing Services Co-pay for Medicare covered hearing exam $10.00 Co-pay for annual hearing exam $10.00 Hearing aid appliance $330.00 to $380.00 Transportation Not covered Dental Optional plan available
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PRESCRIPTION DRUG COVERAGE AARP Medicare Complete Plan 1 (HMO)
Prescription drugs may be covered under Part B or Part D depending on use or place of administration. Typically, drugs administered as part of a physician service or used with a piece of durable medical equipment are billed as Part B and all others are covered under Part D.
Drugs Covered under Medicare Part B (amount you will pay): 20% of the cost for Part B-covered chemotherapy drugs and other Part B drugs. Drugs Covered under Medicare Part D: ANNUAL DEDUCTIBLE: $205.00 (for brand and specialty drugs) Are my doctors in this plan’s network? Yes No
• Name _____________________________ Phone _______________
• Name _____________________________ Phone _______________
• Name _____________________________ Phone _______________
• Name _____________________________ Phone _______________
• Name _____________________________ Phone _______________
Is my pharmacy in the plan’s network?
• Name _____________________________ Phone _______________
• Name _____________________________ Phone _______________
Does this plan offer any extra services? Dental Vision
Hearing Gym Membership
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AARP MedicareComplete Plan 2 (HMO) Plan Number H0609-027 STAR RATING = 4.5 STARS
United Healthcare 1-800-555-5757
aarpmedicareplans.com Out-of-Network Services No coverage Additional Monthly Premium for this plan $0.00 Maximum out-of-pocket limit $3,500.00 Inpatient Hospital Optum Medical Network Only Co-pay per day for days 1 –7 $155.00 Co-pay per day for days 8 – beyond $0.00 Skilled Nursing Facility Co-pay per day for days 1 – 20 $0.00 Co-pay per day for days 21 – 42 $160.00 Co-pay per day for days 43 – 100 $0.00 Outpatient Mental Health Co-pay per visit $30.00 to $40.00 Emergency/Urgent Care Co-pay per hospital emergency room visit $75.00 Co-pay per visit for urgent care $25.00 to $40.00 Foreign Travel Emergency Coverage Check with plan Ambulance Services Co-pay per trip $150.00 Physician Services Co-pay for Primary Care Physician $0.00 Co-pay for Specialist $25.00 Physical, Occupational, Speech Therapy Co-pay per visit $25.00 Routine Podiatry Service Co-pay per visit (Medicare covered and up to 6 supplemental visits) $25.00 Chiropractic Care Co-pay per visit $20.00 Diagnostic Tests, X-Rays, and Lab Services Clinical/diagnostic lab service $8 to 20% Outpatient Services Facility co-pay at ambulatory surgical center $155.00 Facility co-pay per outpatient hospital facility visit $155.00 Prescription Drugs See Your Plan Comparison
or Contact plan Home Health Care Co-pay per visit $0.00 Durable Medical Equipment (DME) Co-pay per item for Diabetic supplies $0.00 Co-pay per piece of equipment 20% Co-pay per prosthetic device 20% Vision Services Co-pay per Medicare covered eye exam & eyewear post-cataract surgery $0.00 to $20.00 Co-pay per annual vision exam $20.00 Frames/lenses/contacts benefit (every 2 years) $70.00/NO COST/$105.00 Hearing Services Co-pay for Medicare covered hearing exam $0.00 Co-pay for annual hearing exam $0.00 Hearing aid appliance $330.00 to $380.00 Transportation Not covered Dental Optional plan available
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PRESCRIPTION DRUG COVERAGE AARP Medicare Complete Plan 2 (HMO)
Prescription drugs may be covered under Part B or Part D depending on use or place of administration. Typically, drugs administered as part of a physician service or used with a piece of durable medical equipment are billed as Part B and all others are covered under Part D.
Drugs Covered under Medicare Part B (amount you will pay): 20% of the cost for Part B-covered chemotherapy drugs and other Part B drugs. Drugs Covered under Medicare Part D: ANNUAL DEDUCTIBLE: $0.00 (for brand and specialty drugs) Are my doctors in this plan’s network? Yes No
• Name _____________________________ Phone _______________
• Name _____________________________ Phone _______________
• Name _____________________________ Phone _______________
• Name _____________________________ Phone _______________
• Name _____________________________ Phone _______________
Is my pharmacy in the plan’s network?
• Name _____________________________ Phone _______________
• Name _____________________________ Phone _______________
Does this plan offer any extra services? Dental Vision
Hearing Gym Membership
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Aetna Medicare Prime Plan (HMO) Plan Number H3931-092 STAR RATING = 4 STARS
Aetna Medicare 1-855-338-7027
aetnamedicare.com Out-of-Network Services No coverage Additional Monthly Premium for this plan $0.00 Maximum out-of-pocket limit $3,000.00 Inpatient Hospital Banner Hospitals and select other hospitals Co-pay per day for days 1 – 7 $195.00 Co-pay per day for days 8 – beyond $0.00 Skilled Nursing Facility Co-pay per day for days 1 – 20 $20.00 Co-pay per day for days 21 – 100 $160.00 Outpatient Mental Health Co-pay per visit $30.00 Emergency/Urgent Care Co-pay per hospital emergency room visit $75.00 Co-pay per visit for urgent care $60.00 Foreign Travel Emergency Coverage Check with plan Ambulance Services Co-pay per trip $315.00 Physician Services Co-pay for Primary Care Physician $0.00 Co-pay for Specialist $25.00 Physical, Occupational, Speech Therapy Co-pay per visit $30.00 Routine Podiatry Service Co-pay per Medicare-covered visit $30.00 Chiropractic Care Co-pay per visit $20.00 Diagnostic Tests, X-Rays, and Lab Services Clinical/diagnostic lab service $0.00 to 250.00 Outpatient Services Facility co-pay at ambulatory surgical center $195.00 Facility co-pay per outpatient hospital facility visit $195.00 Prescription Drugs See Your Plan Comparison
or Contact plan Home Health Care Co-pay per visit $0.00 Durable Medical Equipment (DME) Co-pay per item for Diabetic supplies $0.00 to 20% Co-pay per piece of equipment 20% Co-pay per prosthetic device 20% Vision Services Co-pay per Medicare covered eye exam & eyewear post-cataract surgery $0.00 to $30.00 Co-pay per annual vision exam $0.00 Eyeglasses or contacts annual benefit Optional plan available Hearing Services Co-pay for Medicare covered diagnostic hearing exam $25.00 Co-pay for routine annual hearing exam $0.00 Hearing aid appliance Optional plan available Transportation Not covered Dental Optional plan available
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PRESCRIPTION DRUG COVERAGE Aetna Medicare Prime Plan (HMO)
Prescription drugs may be covered under Part B or Part D depending on use or place of administration. Typically, drugs administered as part of a physician service or used with a piece of durable medical equipment are billed as Part B and all others are covered under Part D.
Drugs Covered under Medicare Part B (amount you will pay): 20% of the cost for Part B-covered chemotherapy drugs and other Part B drugs. Drugs Covered under Medicare Part D: ANNUAL DEDUCTIBLE: $0.00 Are my doctors in this plan’s network? Yes No
• Name _____________________________ Phone _______________
• Name _____________________________ Phone _______________
• Name _____________________________ Phone _______________
• Name _____________________________ Phone _______________
• Name _____________________________ Phone _______________
Is my pharmacy in the plan’s network?
• Name _____________________________ Phone _______________
• Name _____________________________ Phone _______________
Does this plan offer any extra services? Dental Vision
Hearing Gym Membership
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Blue Medicare Advantage Classic (HMO) Plan Number H0302-006 STAR RATING = 3.5 STARS
Blue Cross Blue Shield 1-888-274-0367
azbluemedicare.com Out-of-Network Services No coverage Additional Monthly Premium for this plan $0.00 Maximum out-of-pocket limit $3,200.00 Inpatient Hospital Banner Health Network and Other Providers Co-pay per day for days 1 – 7 $190.00 Co-pay per day for days 8 – beyond $0.00 Skilled Nursing Facility Co-pay per day for days 1 – 10 $0.00 Co-pay per day for days 11 – 20 $20.00 Co-pay per day for days 21 – 100 $120.00 Outpatient Mental Health Co-pay per visit $20.00 Emergency/Urgent Care Co-pay per hospital emergency room visit $75.00 Co-pay per visit for urgent care $25.00 Foreign Travel Emergency Coverage Check with plan Ambulance Services Co-pay per trip $200.00 Physician Services Co-pay for Primary Care Physician $0.00 Co-pay for Specialist $30.00 Physical, Occupational, Speech Therapy Co-pay per visit $15.00 to $30.00 Routine Podiatry Service Co-pay per visit $30.00 Chiropractic Care Co-pay per visit $20.00 Diagnostic Tests, X-Rays, and Lab Services Clinical/diagnostic lab service $5.00 to $300.00 (or 20%) Outpatient Services Facility co-pay at ambulatory surgical center $10.00 to $260.00 (or 20%) Facility co-pay per outpatient hospital facility visit $10.00 to $260.00 (or 20%) Prescription Drugs See Your Plan Comparison
or Contact plan Home Health Care Co-pay per visit $0.00 Durable Medical Equipment (DME) Co-pay per item for Diabetic supplies $0.00 to 20% Co-pay per piece of equipment 20% Co-pay per prosthetic device 20% Vision Services Co-pay per Medicare covered eye exam & eyewear post-cataract surgery $30.00 to 20% Co-pay per annual vision exam No coverage Frames/lenses/contacts No coverage Hearing Services Co-pay for Medicare covered hearing exam $0.00 Co-pay for annual hearing exam No coverage Hearing aid appliance (every 2 years) No coverage Transportation No coverage Dental No coverage
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PRESCRIPTION DRUG COVERAGE Blue Medicare Advantage Classic (HMO)
Prescription drugs may be covered under Part B or Part D depending on use or place of administration. Typically, drugs administered as part of a physician service or used with a piece of durable medical equipment are billed as Part B and all others are covered under Part D.
Drugs Covered under Medicare Part B (amount you will pay): 20% of the cost for Part B-covered chemotherapy drugs and other Part B drugs. Drugs Covered under Medicare Part D: ANNUAL DEDUCTIBLE: $0.00 Are my doctors in this plan’s network? Yes No
• Name _____________________________ Phone _______________
• Name _____________________________ Phone _______________
• Name _____________________________ Phone _______________
• Name _____________________________ Phone _______________
• Name _____________________________ Phone _______________
Is my pharmacy in the plan’s network?
• Name _____________________________ Phone _______________
• Name _____________________________ Phone _______________
Does this plan offer any extra services? Dental Vision
Hearing Gym Membership
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Blue Medicare Advantage Plus (HMO) Plan Number H0302-001 STAR RATING = 3.5 STARS
Blue Cross Blue Shield 1-888-274-0367
azbluemedicare.com Out-of-Network Services No coverage Additional Monthly Premium for this plan $32.00 (LIS $0.00) Maximum out-of-pocket limit $3,200.00 Inpatient Hospital Banner Health Network and Other Providers Co-pay per day for days 1 – 7 $160.00 Co-pay per day for days 8 – beyond $0.00 Skilled Nursing Facility Co-pay per day for days 1 – 10 $0.00 Co-pay per day for days 11 – 20 $20.00 Co-pay per day for days 21-100 $100.00 Outpatient Mental Health Co-pay per visit $20.00 Emergency/Urgent Care Co-pay per hospital emergency room visit $75.00 Co-pay per visit for urgent care $25.00 Foreign Travel Emergency Coverage Check with plan Ambulance Services Co-pay per trip $125.00 Physician Services Co-pay for Primary Care Physician $0.00 Co-pay for Specialist $15.00 Physical, Occupational, Speech Therapy Co-pay per visit $10.00 to $15.00 Routine Podiatry Service Co-pay per visit $15.00 Chiropractic Care Co-pay per visit $20.00 Diagnostic Tests, X-Rays, and Lab Services Clinical/diagnostic lab service $0.00 to $275.00 (or 20%) Outpatient Services Facility co-pay at ambulatory surgical center $10.00 to $200.00 (or 20%) Facility co-pay per outpatient hospital facility visit $10.00 to $200.00 (or 20%) Prescription Drugs See Your Plan Comparison
or Contact plan Home Health Care Co-pay per visit (includes respite care) $0.00 Durable Medical Equipment (DME) Co-pay per item for Diabetic supplies $0.00 to 20% Co-pay per piece of equipment 20% Co-pay per prosthetic device 20% Vision Services Co-pay per Medicare covered eye exam & eyewear post-cataract surgery $15.00 to 20% Co-pay per annual vision exam No coverage Frames/lenses/contacts No coverage Hearing Services Co-pay for Medicare covered hearing exam $0.00 Co-pay for annual hearing exam No coverage Hearing aid appliance No coverage Transportation No coverage Dental (cleaning, x-ray, oral exam annually) Covers up to $500.00
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PRESCRIPTION DRUG COVERAGE Blue Medicare Advantage Plus (HMO)
Prescription drugs may be covered under Part B or Part D depending on use or place of administration. Typically, drugs administered as part of a physician service or used with a piece of durable medical equipment are billed as Part B and all others are covered under Part D.
Drugs Covered under Medicare Part B (amount you will pay): 20% of the cost for Part B-covered chemotherapy drugs and other Part B drugs. Drugs Covered under Medicare Part D: ANNUAL DEDUCTIBLE: $0.00 Are my doctors in this plan’s network? Yes No
• Name _____________________________ Phone _______________
• Name _____________________________ Phone _______________
• Name _____________________________ Phone _______________
• Name _____________________________ Phone _______________
• Name _____________________________ Phone _______________
Is my pharmacy in the plan’s network?
• Name _____________________________ Phone _______________
• Name _____________________________ Phone _______________
Does this plan offer any extra services? Dental Vision
Hearing Gym Membership
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CIGNA HealthSpring Preferred (HMO) Plan Number H0354-001 STAR RATING = 4.5
CIGNA 1-855-561-3811
cignamedicare.com Out-of-Network Services No coverage Additional Monthly Premium for this plan $0.00 Maximum out-of-pocket limit $5,000.00 Inpatient Hospital Co-pay per day for days 1 – 7 $250.00 Co-pay per day for days 8 – beyond $0.00 Skilled Nursing Facility Co-pay per day for days 1 – 20 $0.00 Co-pay per day for days 21 – 100 $164.00 Outpatient Mental Health Co-pay per visit $40.00 Emergency/Urgent Care Co-pay per hospital emergency room visit $75.00 Co-pay per visit for urgent care $25.00 Foreign Travel Emergency Coverage Check with plan Ambulance Services Co-pay per trip $300.00 Physician Services Co-pay for Primary Care Physician $0.00 Co-pay for Specialist $30.00 Physical, Occupational, Speech Therapy Co-pay per visit $30.00 Routine Podiatry Service Co-pay per Medicare-covered visit $30.00 Co-pay for each supplemental routine visit $30.00 Chiropractic Care Co-pay per visit (up to 12 routine visits per year) $20.00 Diagnostic Tests, X-Rays, and Lab Services Clinical/diagnostic lab service $0.00 to 20% Outpatient Services Facility co-pay at ambulatory surgical center $0.00 to $75.00 Facility co-pay per outpatient hospital facility visit $0.00 to $325.00 Prescription Drugs See Your Plan Comparison
or Contact plan Home Health Care Co-pay per visit $0.00 Durable Medical Equipment (DME) Co-pay per item for Diabetic supplies $0.00 Co-pay per piece of equipment 20% Co-pay per prosthetic device 20% Vision Services Co-pay per Medicare covered eye exam & eyewear post-cataract surgery $0.00 to $30.00 Co-pay per vision exam (every 2 years) $30.00 Co-pay for eyeglasses or contacts No coverage Hearing Services Co-pay for Medicare covered diagnostic hearing exam $30.00 Co-pay for routine hearing exam $30.00 Hearing aid appliance No coverage Transportation No coverage Dental Optional plan available
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PRESCRIPTION DRUG COVERAGE CIGNA HealthSpring Preferred (HMO)
Prescription drugs may be covered under Part B or Part D depending on use or place of administration. Typically, drugs administered as part of a physician service or used with a piece of durable medical equipment are billed as Part B and all others are covered under Part D.
Drugs Covered under Medicare Part B (amount you will pay): 20% of the cost for Part B-covered chemotherapy drugs and other Part B drugs. Drugs Covered under Medicare Part D: ANNUAL DEDUCTIBLE: $0.00 Are my doctors in this plan’s network? Yes No
• Name _____________________________ Phone _______________
• Name _____________________________ Phone _______________
• Name _____________________________ Phone _______________
• Name _____________________________ Phone _______________
• Name _____________________________ Phone _______________
Is my pharmacy in the plan’s network?
• Name _____________________________ Phone _______________
• Name _____________________________ Phone _______________
Does this plan offer any extra services? Dental Vision
Hearing Gym Membership
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Health Net Ruby 1 (HMO) Plan Number H0351-043 STAR RATING = 3 STARS
Health Net of AZ 1-800-333-3930 healthnet.com
Out-of-Network Services No coverage Additional Monthly Premium for this plan $59.00 (LIS $24.20) Maximum out-of-pocket limit $3,800.00 Inpatient Hospital Arizona Priority Care Network Co-pay per day for days 1 -5 $100.00 Co-pay per day for days 6 and beyond $0.00 Skilled Nursing Facility Co-pay per day for days 1 – 20 $0 Co-pay per day for days 21 – 100 $100.00 Outpatient Mental Health Co-pay per visit $15.00 Emergency/Urgent Care Co-pay per hospital emergency room visit $75.00 Co-pay per visit for urgent care $20.00 Foreign Travel Emergency Coverage Check with plan Ambulance Services Co-pay per trip $125.00 Physician Services Co-pay for Primary Care Physician $0.00 Co-pay for Specialist $15.00 Physical, Occupational, Speech Therapy Co-pay per visit $10.00 Routine Podiatry Service Co-pay per Medicare-covered visit $15.00 Chiropractic Care Co-pay per visit (optional plan available with additional visits covered) $20.00 Diagnostic Tests, X-Rays, and Lab Services Clinical/diagnostic lab service $0.00 to $200.00 (or 20%) Outpatient Services Facility co-pay at ambulatory surgical center $50.00 Facility co-pay per outpatient hospital facility visit $75.00 Prescription Drugs See Your Plan Comparison
or Contact plan Home Health Care Co-pay per visit $0.00 Durable Medical Equipment (DME) Co-pay per item for Diabetic supplies $0.00 Co-pay per piece of equipment 20% Co-pay per prosthetic device 20% Vision Services Co-pay per Medicare covered eye exam $0.00 to $10.00 Co-pay per annual vision exam Optional plan available Frames/lenses/contacts benefit Optional plan available Hearing Services Co-pay for Medicare covered hearing exam $15.00 Co-pay for annual hearing exam $ 0 Hearing aid appliance (every 3 years) $ 0 Transportation No coverage Dental Optional plan available
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PRESCRIPTION DRUG COVERAGE Health Net Ruby 1 (HMO)
Prescription drugs may be covered under Part B or Part D depending on use or place of administration. Typically, drugs administered as part of a physician service or used with a piece of durable medical equipment are billed as Part B and all others are covered under Part D.
Drugs Covered under Medicare Part B (amount you will pay): 20% of the cost for Part B-covered chemotherapy drugs and other Part B drugs. Drugs Covered under Medicare Part D: ANNUAL DEDUCTIBLE: $0.00 Are my doctors in this plan’s network? Yes No
• Name _____________________________ Phone _______________
• Name _____________________________ Phone _______________
• Name _____________________________ Phone _______________
• Name _____________________________ Phone _______________
• Name _____________________________ Phone _______________
Is my pharmacy in the plan’s network?
• Name _____________________________ Phone _______________
• Name _____________________________ Phone _______________
Does this plan offer any extra services? Dental Vision
Hearing Gym Membership
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Health Net Ruby Select (HMO) Plan Number H0351-040 STAR RATING = 3 STARS
Health Net of AZ 1-800-333-3930 healthnet.com
Out-of-Network Services No coverage Additional Monthly Premium for this plan $0.00 Maximum out-of-pocket limit $4,000.00 Inpatient Hospital Arizona Priority Care Network Co-pay per day for days 1 – 6 $195.00 Co-pay per day for days 6 and beyond $0.00 Skilled Nursing Facility Co-pay per day for days 1 – 20 $0 Co-pay per day for days 21 – 100 $150.00 Outpatient Mental Health Co-pay per visit $25.00 Emergency/Urgent Care Co-pay per hospital emergency room visit $75.00 Co-pay per visit for urgent care $20.00 Foreign Travel Emergency Coverage Check with plan Ambulance Services Co-pay per trip $275.00 Physician Services Co-pay for Primary Care Physician $0.00 Co-pay for Specialist $25.00 Physical, Occupational, Speech Therapy Co-pay per visit $20.00 Routine Podiatry Service Co-pay per Medicare-covered visit $25.00 Chiropractic Care Co-pay per visit (optional plan available with additional visits covered) $20.00 Diagnostic Tests, X-Rays, and Lab Services Clinical/diagnostic lab service $0.00 to $200.00 (or 20%) Outpatient Services Facility co-pay at ambulatory surgical center $100.00 Facility co-pay per outpatient hospital facility visit $150.00 Prescription Drugs See Your Plan Comparison
or Contact plan Home Health Care Co-pay per visit $0.00 Durable Medical Equipment (DME) Co-pay per item for Diabetic supplies $0.00 Co-pay per piece of equipment 20% Co-pay per prosthetic device 20% Vision Services Co-pay per Medicare covered eye exam & eyewear post-cataract surgery $0.00 to $10.00 Co-pay per annual vision exam Optional plan available Frames/lenses/contacts benefit Optional plan available Hearing Services Co-pay for Medicare covered hearing exam $25.00 Co-pay for annual hearing exam $0.00 Hearing aid appliance (every 3 years) $0.00 Transportation No coverage Dental Optional plan available
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PRESCRIPTION DRUG COVERAGE Health Net Ruby Select (HMO)
Prescription drugs may be covered under Part B or Part D depending on use or place of administration. Typically, drugs administered as part of a physician service or used with a piece of durable medical equipment are billed as Part B and all others are covered under Part D.
Drugs Covered under Medicare Part B (amount you will pay): 20% of the cost for Part B-covered chemotherapy drugs and other Part B drugs. Drugs Covered under Medicare Part D: ANNUAL DEDUCTIBLE: $0.00 Are my doctors in this plan’s network? Yes No
• Name _____________________________ Phone _______________
• Name _____________________________ Phone _______________
• Name _____________________________ Phone _______________
• Name _____________________________ Phone _______________
• Name _____________________________ Phone _______________
Is my pharmacy in the plan’s network?
• Name _____________________________ Phone _______________
• Name _____________________________ Phone _______________
Does this plan offer any extra services? Dental Vision
Hearing Gym Membership
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Humana Gold Plus (HMO) Plan Number H2649-032 STAR RATING = 4 STARS
Humana 1-800-833-2364
Humana-medicare.com Out-of-Network Coverage No Coverage Additional Monthly Premium for this plan $0.00 Maximum out-of-pocket limit $5,500 Inpatient Hospital NOT ACCEPTED AT BARROW NEUROLOGICAL INSTITUTE Co-pay per day for days 1 – 7 $225.00 Co-pay per day for days 8 – beyond $0.00 Skilled Nursing Facility Co-pay per day for days 1 – 20 $0 Co-pay per day for days 21 – 100 $164.50 Outpatient Mental Health Co-pay per visit $40.00 Emergency/Urgent Care Co-pay per hospital emergency room visit $75.00 Co-pay per visit for urgent care $35.00 Foreign Travel Emergency Coverage Check with plan Ambulance Services Co-pay per trip $265.00 Physician Services Co-pay for Primary Care Physician $0.00 Co-pay for Specialist $35.00 Physical, Occupational, Speech Therapy Co-pay per visit $35.00 Routine Podiatry Service Co-pay per Medicare-covered visit $35.00 Chiropractic Care Co-pay per visit $20.00 Diagnostic Tests, X-Rays, and Lab Services Clinical/diagnostic lab service $0.00 to $200.00 (or 20%) Outpatient Services Facility co-pay at ambulatory surgical center $175.00 Facility co-pay per outpatient hospital facility visit $200.00 Prescription Drugs See Your Plan Comparison
or Contact plan Home Health Care Co-pay per visit $0.00 Durable Medical Equipment (DME) Co-pay per item for Diabetic supplies 0% to 20% Co-pay per piece of equipment 20% Co-pay per prosthetic device 20% Vision Services Co-pay per Medicare covered eye exam & eyewear post-cataract surgery $35.00 Co-pay per annual vision exam $0.00 Frames/lenses/contacts Optional plan available Hearing Services Co-pay for Medicare covered hearing exam $35.00 Co-pay for annual hearing exam $0.00 Hearing aid appliance copay $699.00 - $999.00 Transportation No coverage Dental Limited Services Optional plan available
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PRESCRIPTION DRUG COVERAGE Humana Gold Plus (HMO)
Prescription drugs may be covered under Part B or Part D depending on use or place of administration. Typically, drugs administered as part of a physician service or used with a piece of durable medical equipment are billed as Part B and all others are covered under Part D.
Drugs Covered under Medicare Part B (amount you will pay): 20% of the cost for Part B-covered chemotherapy drugs and other Part B drugs. Drugs Covered under Medicare Part D: ANNUAL DEDUCTIBLE: $225.00 (for brand and specialty drugs) Are my doctors in this plan’s network? Yes No
• Name _____________________________ Phone _______________
• Name _____________________________ Phone _______________
• Name _____________________________ Phone _______________
• Name _____________________________ Phone _______________
• Name _____________________________ Phone _______________
Is my pharmacy in the plan’s network?
• Name _____________________________ Phone _______________
• Name _____________________________ Phone _______________
Does this plan offer any extra services? Dental Vision
Hearing Gym Membership
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Humana Gold Plus (HMO) Plan Number H2649-030 STAR RATING = 4 STARS
Humana 1-800-833-2364
Humana-medicare.com Additional Monthly Premium for this plan $85.00 (LIS $85.00) Maximum out-of-pocket limit $4,900 Inpatient Hospital NOT ACCEPTED AT BARROW NEUROLOGICAL INSTITUTE Co-pay per day for days 1 – 6 $289.00 Co-pay per day for days 7 – beyond $0.00 Skilled Nursing Facility Co-pay per day for days 1 – 20 $0 Co-pay per day for days 21 – 100 $164.50 Outpatient Mental Health Co-pay per visit $40.00 Emergency/Urgent Care Co-pay per hospital emergency room visit $75.00 Co-pay per visit for urgent care $45.00 Foreign Travel Emergency Coverage Check with plan Ambulance Services Co-pay per trip $265.00 Physician Services Co-pay for Primary Care Physician $5.00 Co-pay for Specialist $45.00 Physical, Occupational, Speech Therapy Co-pay per visit $30.00 to $45.00 Routine Podiatry Service Co-pay per Medicare-covered visit $45.00 Chiropractic Care Co-pay per visit $40.00 Diagnostic Tests, X-Rays, and Lab Services Clinical/diagnostic lab service $0.00 to $264.00 (or 20%) Outpatient Services Facility co-pay at ambulatory surgical center $239.00 Facility co-pay per outpatient hospital facility visit $264.00 Prescription Drugs See Your Plan Comparison
or Contact plan Home Health Care Co-pay per visit $0.00 Durable Medical Equipment (DME) Co-pay per item for Diabetic supplies 0% to 20% Co-pay per piece of equipment 20% Co-pay per prosthetic device 20% Vision Services Co-pay per Medicare covered eye exam & eyewear post-cataract surgery $0.00 to $45.00 Co-pay per annual vision exam $0.00 Frames/lenses/contacts $200.00 annual benefit Hearing Services Co-pay for Medicare covered hearing exam $45.00 Co-pay for annual hearing exam $0.00 Hearing aid appliance copay $699.00 – $999.00 Transportation (12 one way trips, not to exceed 25miles per trip ) $0.00 Dental (limited services) Optional plan available
22
PRESCRIPTION DRUG COVERAGE Humana Gold Plus (HMO)
Prescription drugs may be covered under Part B or Part D depending on use or place of administration. Typically, drugs administered as part of a physician service or used with a piece of durable medical equipment are billed as Part B and all others are covered under Part D.
Drugs Covered under Medicare Part B (amount you will pay): 20% of the cost for Part B-covered chemotherapy drugs and other Part B drugs. Drugs Covered under Medicare Part D: ANNUAL DEDUCTIBLE: $205.00 (for brand and specialty drugs) Are my doctors in this plan’s network? Yes No
• Name _____________________________ Phone _______________
• Name _____________________________ Phone _______________
• Name _____________________________ Phone _______________
• Name _____________________________ Phone _______________
• Name _____________________________ Phone _______________
Is my pharmacy in the plan’s network?
• Name _____________________________ Phone _______________
• Name _____________________________ Phone _______________
Does this plan offer any extra services? Dental Vision
Hearing Gym Membership
23
Health Net Green (HMO) Plan Number H0351-030 STAR RATING = 3 STARS
Health Net of AZ 1-800-333-3930
healthnet.com/medicare Out-of-Network Services No coverage Additional Monthly Premium for this plan $0.00 Maximum out-of-pocket limit $6,700.00 Inpatient Hospital Not Accepted at any Scottsdale Health Care Facility Co-pay per day for days 1 – 8 $195.00 Co-pay per day for days 9 – beyond $0.00 Skilled Nursing Facility Co-pay per day for days 1 – 20 $0 Co-pay per day for days 21 – 100 $100.00 Outpatient Mental Health Co-pay per visit $35.00 Emergency/Urgent Care Co-pay per hospital emergency room visit (waived if admitted) $75.00 Co-pay per visit for urgent care $20.00 Foreign Travel Emergency Coverage Check with plan Ambulance Services Co-pay per trip $300.00 Physician Services Co-pay for Primary Care Physician $5.00 Co-pay for Specialist $35.00 Physical, Occupational, Speech Therapy Co-pay per visit $25.00 Routine Podiatry Service Co-pay per visit $35.00 Chiropractic Care Co-pay per Medicare-covered visit (optional plan w/ additional visits) $20.00 Diagnostic Tests, X-Rays, and Lab Services Clinical/diagnostic lab service $0.00 to $200.00 (or 20%) Outpatient Services Facility co-pay at ambulatory surgical center $125.00 Facility co-pay per outpatient hospital facility visit $175.00 Prescription Drugs No coverage 20% of Part B chemotherapy and other Part B drugs 20% Home Health Care Co-pay per visit $0.00 Durable Medical Equipment (DME) Co-pay per item for Diabetic supplies $0.00 Co-pay per piece of equipment 20% Co-pay per prosthetic device 20% Vision Services Co-pay per Medicare covered eye exam & eyewear post-cataract surgery $0.00 to $10.00 Co-pay per annual vision exam Optional plan available Frames/lenses/contacts Optional plan available Hearing Services Co-pay for Medicare covered hearing exam $15.00 Co-pay for annual hearing exam No coverage Hearing aid appliance No coverage Transportation No coverage Dental (limited services) Optional plan available
24
Health Net Green (HMO)
THIS PLAN DOES NOT
PROVIDE PRESCRIPTION
DRUG COVERAGE Are my doctors in this plan’s network? Yes No
• Name _____________________________ Phone _______________
• Name _____________________________ Phone _______________
• Name _____________________________ Phone _______________
• Name _____________________________ Phone _______________
• Name _____________________________ Phone _______________
Is my pharmacy in the plan’s network?
• Name _____________________________ Phone _______________
• Name _____________________________ Phone _______________
Does this plan offer any extra services? Dental Vision
Hearing Gym Membership
25
Preferred Provider Organizations (PPO)
A health care plan in which you use doctors, hospitals, and providers that belong to the network. You can receive services outside of the network for an additional cost. You do not need a referral from a primary care physician to see a specialist. Plans with Prescription Drug Coverage: Local PPO (Maricopa county-wide only) Page 1. Aetna Medicare Prime Plan (MAPD) 27 Select Counties PPO (Maricopa, Pima, Pinal & Santa Cruz county-wide) 2. Humana Choice PPO (MAPD) 29 Regional PPO (provider network is state-wide) 3. Humana Choice Regional PPO (MAPD) 31 Plans WITHOUT Prescription Drug Coverage: 4. Humana Choice Regional PPO (MA) 33
Private Fee For Service PFFS
Private Fee For Service (nationwide coverage w/o a network or contracts)
1. Humana Gold Choice (PFFS) 35
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27
Aetna Medicare Prime Plan (PPO) Plan Number H5521-100 STAR RATING = 4 STARS
Aetna Medicare 1-855-338-7027
aetnamedicare.com Out-of-Network Services Up to 40% Additional Monthly Premium for this plan $89.00 (LIS $75.50) Maximum out-of-pocket limit in-network/out-of-network $6,700.00/$10,000 Inpatient Hospital Banner Hospitals and select other hospitals Co-pay per day for days 1 – 6 $255.00 Co-pay per day for days 7 – beyond $0.00 Skilled Nursing Facility Co-pay per day for days 1 – 20 $0.00 Co-pay per day for days 21 – 100 P$160.00 Outpatient Mental Health Co-pay per visit $40.00 Emergency/Urgent Care Co-pay per hospital emergency room visit $75.00 Co-pay per visit for urgent care $60.00 Foreign Travel Emergency Coverage $75.00 Ambulance Services Co-pay per trip $325.00 Physician Services Co-pay for Primary Care Physician $5.00 Co-pay for Specialist $25.00 Physical, Occupational, Speech Therapy Co-pay per visit $25.00 Routine Podiatry Service Co-pay per Medicare-covered visit $25.00 Chiropractic Care Co-pay per visit $20.00 Diagnostic Tests, X-Rays, and Lab Services Clinical/diagnostic lab service $0-$25.00 to 20% Outpatient Services Facility co-pay at ambulatory surgical center $195.00 Facility co-pay per outpatient hospital facility visit $25.00 to $195.00 Prescription Drugs See Your Plan Comparison
or Contact plan Home Health Care Co-pay per visit $0.00 Durable Medical Equipment (DME) Co-pay per item for Diabetic supplies 0% to 20% Co-pay per piece of equipment 20% Co-pay per prosthetic device 20% Vision Services Co-pay per Medicare covered eye exam & eyewear post-cataract surgery $0.00 Co-pay per annual vision exam $0.00 Eyeglasses or contacts annual benefit – plan pays up to $125.00/year Limited coverage Hearing Services Co-pay for Medicare covered diagnostic hearing exam $25.00 Co-pay for routine annual hearing exam $0.00 Hearing aid appliance benefit Plan pays up to $500 Transportation Not covered Dental (preventive & comprehensive dental services) Plan pays up to $1000
28
PRESCRIPTION DRUG COVERAGE Aetna Medicare Prime Plan (PPO)
Prescription drugs may be covered under Part B or Part D depending on use or place of administration. Typically, drugs administered as part of a physician service or used with a piece of durable medical equipment are billed as Part B and all others are covered under Part D.
Drugs Covered under Medicare Part B (amount you will pay): 20% of the cost for Part B-covered chemotherapy drugs and other Part B drugs. Drugs Covered under Medicare Part D: ANNUAL DEDUCTIBLE: $0.00 Are my doctors in this plan’s network? Yes No
• Name _____________________________ Phone _______________
• Name _____________________________ Phone _______________
• Name _____________________________ Phone _______________
• Name _____________________________ Phone _______________
• Name _____________________________ Phone _______________
Is my pharmacy in the plan’s network?
• Name _____________________________ Phone _______________
• Name _____________________________ Phone _______________
Does this plan offer any extra services? Dental Vision
Hearing Gym Membership
29
Humana Choice PPO (MAPD) Plan Number H6609-133 STAR RATING = 3.5 STARS
Humana Health Plan 1-800-833-2364
humana-medicare.com Out-of- Network Services; contact plan for out-of-network costs Up to 50% Additional Monthly Premium for this plan $135.00 ($99.90 LIS) Maximum out-of-pocket limit in network/out of network $6,700.00/$10,000 Inpatient Hospital (In-Network) Co-pay per day for days 1-6 $289.00 Co-pay per day for days 7 - beyond $0.00 Skilled Nursing Facility (In Network) Co-pay per day for days 1 – 20 $0.00 Co-pay per day for days 21 – 100 $164.50 Outpatient Mental Health Co-pay per visit $40.00 Emergency/Urgent Care Co-pay per hospital emergency room visit $75.00 Co-pay per visit for urgent care $45.00 Foreign Travel Emergency Coverage Check with plan Ambulance Services Co-pay per trip $265.00 Physician Services Co-pay for Primary Care Physician $5.00 Co-pay for Specialist $45.00 Physical, Occupational, Speech Therapy Co-pay per visit $30.00-$45.00 Routine Podiatry Service Co-pay per Medicare-Covered visit $45.00 Chiropractic Care Co-pay per visit $20.00 Diagnostic Tests, X-Rays, and Lab Services Clinical/diagnostic lab service $0.00 to $264.00 (or 20%) Outpatient Services Facility co-pay at ambulatory surgical center $239.00 Facility co-pay per outpatient hospital facility visit $264.00 Prescription Drugs See Your Plan
Comparison or Contact Plan
Home Health Care (In Network) Co-pay per visit $0.00 Durable Medical Equipment (DME) Co-pay per item for Diabetic supplies $0.00 to 20% Co-pay per piece of equipment 20% Co-pay per prosthetic device 20% Vision Services Co-pay per Medicare covered eye exam & eyewear post-cataract surgery $0.00 - $45.00 Co-pay per annual vision exam $40.00 Co-pay for Frames/lenses/contacts Optional plan available Hearing Services Co-pay for Medicare covered hearing exam $45.00 Co-pay for annual hearing exam No coverage Hearing aid appliance No coverage Transportation No coverage Dental (limited benefits) Optional plan available
30
PRESCRIPTION DRUG COVERAGE
Humana Choice PPO (MAPD)
Prescription drugs may be covered under Part B or Part D depending on use or place of administration. Typically, drugs administered as part of a physician service or used with a piece of durable medical equipment are billed as Part B and all others are covered under Part D.
Drugs Covered under Medicare Part B (amount you will pay): 20% of the cost for Part B-covered chemotherapy drugs and other Part B drugs. Drugs Covered under Medicare Part D: ANNUAL DEDUCTIBLE: $225.00 (for brand and specialty drugs) Are my doctors in this plan’s network? Yes No
• Name _____________________________ Phone _______________
• Name _____________________________ Phone _______________
• Name _____________________________ Phone _______________
• Name _____________________________ Phone _______________
• Name _____________________________ Phone _______________
Is my pharmacy in the plan’s network?
• Name _____________________________ Phone _______________
• Name _____________________________ Phone _______________
Does this plan offer any extra services? Dental Vision
Hearing Gym Membership
31
Humana Choice Regional PPO (MAPD) Plan Number R5826-014 STAR RATING = 3 STARS
Humana Health Plan 1-800-833-2364
humana-medicare.com Out-of- Network Services; contact plan for out-of-network costs Up to 50% Additional Monthly Premium for this plan $166.00 ($133.10 LIS) Maximum out-of-pocket limit in network/out of network $6,700.00 Inpatient Hospital (In-Network) Co-pay per day for days 1-6 $254.00 Co-pay per day for days 7 – beyond $0.00 Skilled Nursing Facility (In Network) Co-pay per day for days 1 – 20 $0.00 Co-pay per day for days 21 – 100 $164.50 Outpatient Mental Health Co-pay per visit $40.00 Emergency/Urgent Care Co-pay per hospital emergency room visit $75.00 Co-pay per visit for urgent care $45.00 Foreign Travel Emergency Coverage Check with plan Ambulance Services Co-pay per trip $265.00 Physician Services Co-pay for Primary Care Physician $15.00 Co-pay for Specialist $45.00 Physical, Occupational, Speech Therapy Co-pay per visit $30.00 to $45.00 Routine Podiatry Service Co-pay per Medicare-Covered visit $45.00 Chiropractic Care Co-pay per visit $20.00 Diagnostic Tests, X-Rays, and Lab Services Clinical/diagnostic lab service $0.00 to $264.00 or
20% Outpatient Services Facility co-pay at ambulatory surgical center $239.00 Facility co-pay per outpatient hospital facility visit $264.00 Prescription Drugs See Your Plan Comparison
or Contact plan Home Health Care (In Network) Co-pay per visit $0.00 Durable Medical Equipment (DME) Co-pay per item for Diabetic supplies $0.00 to 20% Co-pay per piece of equipment 20% Co-pay per prosthetic device 20% Vision Services Co-pay per Medicare covered eye exam & eyewear post-cataract surgery $0.00 to $45.00 Annual vision exam – maximum benefit $40.00 Co-pay for Frames/lenses/contacts Optional plan available Hearing Services Co-pay for Medicare covered hearing exam $45.00 Co-pay for annual hearing No coverage Hearing aid appliance No coverage Transportation No coverage Dental Optional plan available
32
PRESCRIPTION DRUG COVERAGE
Humana Choice Regional PPO (MAPD)
Prescription drugs may be covered under Part B or Part D depending on use or place of administration. Typically, drugs administered as part of a physician service or used with a piece of durable medical equipment are billed as Part B and all others are covered under Part D.
Drugs Covered under Medicare Part B (amount you will pay): 20% of the cost for Part B-covered chemotherapy drugs and other Part B drugs. Drugs Covered under Medicare Part D: ANNUAL DEDUCTIBLE: $280.00 (for brand and specialty drugs) Are my doctors in this plan’s network? Yes No
• Name _____________________________ Phone _______________
• Name _____________________________ Phone _______________
• Name _____________________________ Phone _______________
• Name _____________________________ Phone _______________
• Name _____________________________ Phone _______________
Is my pharmacy in the plan’s network?
• Name _____________________________ Phone _______________
• Name _____________________________ Phone _______________
Does this plan offer any extra services? Dental Vision
Hearing Gym Membership
33
Humana Choice Regional PPO (MA) Plan Number R5826-070 STAR RATING = 3 STARS
Humana Health Plan 1-800-833-2364
humana-medicare.com Out-of- Network Services; contact plan for out-of-network costs Up to 50% Additional Monthly Premium for this plan $0.00 Annual Deductible for out of network services $599.00 Maximum out-of-pocket limit in network/out of network $6,700.00/$10,000 Inpatient Hospital (In-Network) Co-pay per day for days 1-6 $289.00 Co-pay per day for days 7 - beyond $0.00 Skilled Nursing Facility (In Network) Co-pay per day for days 1 – 20 $0.00 Co-pay per day for days 21 – 100 $164.50 Outpatient Mental Health Co-pay per visit $40.00 Emergency/Urgent Care Co-pay per hospital emergency room visit $75.00 Co-pay per visit for urgent care $40.00 Foreign Travel Emergency Coverage Check with the plan Ambulance Services Co-pay per trip $265.00 Physician Services Co-pay for Primary Care Physician $15.00 Co-pay for Specialist $40.00 Physical, Occupational, Speech Therapy Co-pay per visit $30.00 to $40.00 Routine Podiatry Service Co-pay per Medicare-Covered visit $40.00 Chiropractic Care Co-pay per visit $20.00 Diagnostic Tests, X-Rays, and Lab Services Clinical/diagnostic lab service $0.00 to 264.00 or 20%) Outpatient Services Facility co-pay at ambulatory surgical center $239.00 Facility co-pay per outpatient hospital facility visit $264.00 Prescription Drugs No coverage Home Health Care (In Network) Co-pay per visit $0.00 Durable Medical Equipment (DME) Co-pay per item for Diabetic supplies $0.00 to 20% Co-pay per piece of equipment 15% Co-pay per prosthetic device 15% Vision Services Co-pay per Medicare covered eye exam & eyewear post-cataract surgery $0.00 - $40.00 Co-pay per annual vision exam $0.00 Co-pay for Frames/lenses/contacts Optional plan available Hearing Services Co-pay for Medicare covered hearing exam $40 Co-pay for annual hearing exam No coverage Hearing aid appliance No coverage Transportation No coverage Dental Optional plan available
34
Humana Choice Regional PPO (MA)
THIS PLAN DOES
NOT PROVIDE
PRESCRIPTION DRUG COVERAGE
Are my doctors in this plan’s network? Yes No
• Name _____________________________ Phone _______________
• Name _____________________________ Phone _______________
• Name _____________________________ Phone _______________
• Name _____________________________ Phone _______________
• Name _____________________________ Phone _______________
Is my pharmacy in the plan’s network?
• Name _____________________________ Phone _______________
• Name _____________________________ Phone _______________
Does this plan offer any extra services? Dental Vision
Hearing Gym Membership
35
Humana Gold Choice (PFFS) Plan Number H8145-103 STAR RATING = 3.5 STARS
Humana Insurance 1-800-833-2364
Humana-medicare.com Out-of-Network Services; contact plan for out-of-network costs Up to 50% Additional Monthly Premium for this plan $192.00 (LIS $162.30) Maximum out-of-pocket limit $6,700.00 Inpatient Hospital Co-pay per day for days 1 – 5 $275.00 Co-pay per day for days 6 – beyond $0.00 Skilled Nursing Facility Co-pay per day for days 1 – 20 $0.00 Co-pay per day for days 21 – 100 $164.50 Outpatient Mental Health Co-pay per visit $40.00 Emergency/Urgent Care Co-pay per hospital emergency room visit $75.00 Co-pay per visit for urgent care $45.00 Foreign Travel Emergency Coverage Check with plan Ambulance Services Co-pay per trip $265.00 Physician Services Co-pay for Primary Care Physician $20.00 Co-pay for Specialist $45.00 Physical, Occupational, Speech Therapy Co-pay per visit $30.00 - $45.00 Routine Podiatry Service Co-pay per Medicare-covered visit $45.00 Chiropractic Care Co-pay per visit $20.00 Diagnostic Tests, X-Rays, and Lab Services Clinical/diagnostic lab service $0.00 -$250.00 or 20 - 25% Outpatient Services Facility co-pay at ambulatory surgical center $225.00 Facility co-pay per outpatient hospital facility visit $250.00 Prescription Drugs See Your Plan Comparison
or Contact plan Home Health Care Co-pay per visit $0.00 Durable Medical Equipment (DME) Co-pay per item for Diabetic supplies 0% to 20% Co-pay per piece of equipment 20% Co-pay per prosthetic device 20% Vision Services Co-pay per Medicare covered eye exam & eyewear post-cataract surgery $0.00 to $45.00 Co-pay per annual vision exam $0.00 Eyeglasses or contacts annual benefit (optional plan available) $130.00 Hearing Services Co-pay for Medicare covered diagnostic hearing exam $45.00 Co-pay for routine annual hearing exam No coverage Hearing aid appliance Optional plan available Transportation No coverage Dental (limited services available for $45.00 co-pay) Optional plan available
36
PRESCRIPTION DRUG COVERAGE Humana Gold Choice (PFFS)
Prescription drugs may be covered under Part B or Part D depending on use or place of administration. Typically, drugs administered as part of a physician service or used with a piece of durable medical equipment are billed as Part B and all others are covered under Part D.
Drugs Covered under Medicare Part B (amount you will pay): 20% of the cost for Part B-covered chemotherapy drugs and other Part B drugs. Drugs Covered under Medicare Part D: ANNUAL DEDUCTIBLE: $225.00 (for brand and specialty drugs) Are my doctors in this plan’s network? Yes No
• Name _____________________________ Phone _______________
• Name _____________________________ Phone _______________
• Name _____________________________ Phone _______________
• Name _____________________________ Phone _______________
• Name _____________________________ Phone _______________
Is my pharmacy in the plan’s network?
• Name _____________________________ Phone _______________
• Name _____________________________ Phone _______________
Does this plan offer any extra services? Dental Vision
